zoran Đogaš
DESCRIPTION
Zoran Đogaš. Opće moždane funkcije Spavanje. SPAVANJE (SLEEP). Složena neurobiolog ija bihejvioralnih značajki spavanja istražuje se više od 40 godina na - mole kulskoj , - staničnoj i - s i stem skoj razini . . SPAVANJE (SLEEP). - PowerPoint PPT PresentationTRANSCRIPT
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Zoran Đogaš
Opće moždane funkcije
Spavanje
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SPAVANJE (SLEEP)
Složena neurobiologija bihejvioralnih značajki spavanja istražuje se više od 40 godina na
- molekulskoj, - staničnoj i - sistemskoj razini.
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SPAVANJE (SLEEP)
Although numerous studies provided substantial insight into physiology and pathology of sleep, many unanswered questions remain about this behavioral state that consumes approximately one third of our lives.
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Origin of sleep Identifying a “sleep substance” It is likely that many factors contribute to
the homeostatic regulation of sleep Posterior hypothalamic lesions produced
prolonged sleeplike state Lesions of the preoptic area in anterior
hypothalamus markedly suppressed sleep This implies that the sleep center may be
located in the hypothalamus.
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Origin of sleep
GABA from the ventrolateral preoptic area (VLPO) of the hypothalamus may inhibit histaminergic activation of the thalamus and cerebral cortex by TMN.
Such a mechanism would allow complex thalamocortical interactions that may result in NREM sleep.
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CortexCortexTe
lenc
epha
lon
Die
ncep
halo
nB
rain
stem
5-HT
NRD
NA
LC
Hist
TMHypoth.
M
Glu
Th
+ +
ACh
Ch1-Ch4
Ch5/Ch6
M
DA
VTA
M
VLPOSleep-on
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GABA (-)
Inhibitory Amino AcidExcitatory Amino Acid
GLUTAMAT (+)
SLEEP
“Pro-sleep substances”
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GABA receptorGABA receptorss Ionotropic
(Cl- ionic channel as a part of the receptor)GABAA, GABAC
Metabotropic(G-protein, second messanger activation)GABAB
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GABA EFFECT ON SLEEPGABA EFFECT ON SLEEP
Agonistic modulators
Barbiturates
Benzodiazepines
Zolpidem, zopiclone
Neuroactive steroids
Agonists
Muscimol, THIP
(GABA(GABAAA effect) effect)
↓ Latency↑ Total sleep↑ NREM, spindles↓ REM
↑ Total Sleep↑ NREM ↓ spindles
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GABA EFFECT ON SLEEPGABA EFFECT ON SLEEP
GABAB Antagonists
GABAC Antagonists
(GABA(GABAB B and GABAand GABAC C effects)effects)
↑ Wakefulness↑ REM
↑ Wakefulness↓ REM↓ SWS
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GABAGABAAA and GABA and GABACC receptor receptorss
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GABAGABABB receptor receptor
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SELECTIVITY?SELECTIVITY?
Anxiolysis
Sedation
Hypnotic effect
Muscle relaxation
(GABA(GABAAA effect) effect)
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SELECTIVITY?SELECTIVITY?
More selective hypnotic effect
Only on BZ 1 (ili 1) receptors
Zolpidem and similar drugs
Search is underway
(GABA(GABAAA effect) effect)
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SELECTIVITY?SELECTIVITY?
Newer studies raise possibilities of more
selective and more effective
“pro - sleep drugs”
(GABA(GABACC effect) effect)
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Stadiji spavanjaStadiji spavanja
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Putovi u koru mozgaPutovi u koru mozga
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Plitko spavanje Church sleep
Car driving sleep
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Sporovalno (duboko) spavanje
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REM spavanje(REM, brzi pokreti očiju)
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Povezani s nekoliko disciplina
•Interna medicina•Pulmologija•Otorinolaringologija •Neurologija•Psihijatrija•Psihologija
POREMEĆAJI SPAVANJA
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Poremećaji spavanja smatraju se čimbenikom rizika za:
-kardiovaskularne bolesti, -depresiju, -ozljede na radnom mjestu, -poteškoće učenja itd.
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Poremećaji spavanja
• Visoka učestalost - rijetko dijagnosticirani• Epidemiološke studije i anketiranje:
oko 70 milijuna Amerikanaca Rosen RC, Zozula R, Jahn EG, Carson JL. Sleep Med 2001;2:47-55.
• U svim dobnim skupinama• Problemi sa spavanjem česti su u trudnica i djece te ugrožavaju
normalan razvitak Santiago RJ, Nolledo SM, Kinzler W, Santiago VT. Ann Intern Med 2001;134:396-408.Stores G, Wiggs L. Arch Dis Child 1998;79:495-7.
• Udruženi s mnogim bolestima
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Poremećaji spavanja • Visoki zdravstveni rizik• Udruženi s povišenim kardiovaskularnim morbiditetom i
mortalitetom • Povezani s različitim duševnim bolestima
Kaplan IH, Sadock JB, Grebb AJ. 1994. p. 699-716.
Prekomjerna pospanost tijekom dana - excessive daytime sleepiness
Umanjena pozornost dovodi do (somnolence)•nesreća i •umanjene kvalitete života
El-Ad B, Korczyn AD. J Neurol Sci 1998;153:192-202.
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Poremećaji spavanja • U SAD, 1995., lijekovi za liječenje insomnije $1.97 milijardi,
više od pola “nonprescription medication” • Izravan trošak procijenjen na $13.9 milijardi.
Walsh JK, Engelhardt CL. Sleep 1999;22:386-93.
• Slabo dijagnosticiranjeU SAD: 17 pozitivnih dijagnoza poremećaja spavanja na milijun povijesti
bolesti Rosen RC, Zozula R, Jahn EG, Carson JL. Sleep Med 2001;2:47-55.
• Mogući uzrok – nepovoljan stav o medicini spavanja ili veliki jaz između znanstvenoistraživačkog rada i edukacije
Rosen R, Mahowald M, Chesson A, Doghramji K, Goldberg R, Moline M, et al.
Sleep 1998;21:235-8.
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• Medicinski fakulteti u nas Ne postoji predmet Medicina spavanja
osim izbornog predmeta na MF Zagreb http://www.mef.hr/katedre/psihijat/spavanje/spavanje.html
Na MF Split fiziologija spavanja – seminar u okviru TNZ Rumboldt Z. Croat Med J 2000;41:361-7.
•Američki pulmolozi u medicini spavanja
Neformalno educirani
Slabo znanje o ne-pulmonarnim poremećajima spavanja Phillips B, Collop N, Goldberg R. Chest 1996;110:1597-602.
Edukacija
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Zrnka Kovačić, Mirela Marendić, Martina Šoljić, Renata Pecotić1, Goran Kardum1 i Zoran Đogaš1
Student medicine, Medicinski fakultet Sveučilišta u Splitu, Split, Hrvatska1 Katedra za neuroznanost, Medicinski fakultet Sveučilišta u Splitu, Split, Hrvatska
ZNANJE I STAVOVI STUDENATA MEDICINE I LIJEČNIKA U SPLITU
O MEDICINI SPAVANJA
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Cilj istraživanja
• Ispitati znanje o medicini spavanja studenata medicine i liječnika
• Odrediti stavove ispitanika o medicini spavanja
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Metode
112 ispitanika
• znanje o medicini spavanja,• znanje o hipertenziji,
• stavovi o medicini spavanja
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Ispitanici
1) studenti druge godine MF Split (46 ili 41%);
2) liječnici na postdiplomskom studiju, II god. (26 ili 23%); 3) liječnici-specijalisti različitih disciplina (40 ili 36%).
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Postupci
Upitnik:
• Sleep Medicine Knowledge Test, • Hypertension Test, and • Sleep Medicine Attitude Test
Statistička analiza:• ANOVA za testiranje razlika među skupinama, • Wilcoxon test za razlike unutar skupina.
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Rezultati na testovima znanjaRezultati na testovima znanja
0,41
0,500,46
0,00
0,10
0,20
0,30
0,40
0,50
0,60
0,70
0,80
0,90
1,00
Students Postgraduates Specialists
Scor
eKnowledge about sleep
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Rezultati na testovima znanjaRezultati na testovima znanja
0,46
0,66
0,73
0,00
0,10
0,20
0,30
0,40
0,50
0,60
0,70
0,80
0,90
1,00
Students Postgraduates Specialists
Scor
eKnowledge about hypertension
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Rezultati na testovima znanjaRezultati na testovima znanja
0,41
0,500,460,46
0,66
0,73
0,00
0,10
0,20
0,30
0,40
0,50
0,60
0,70
0,80
0,90
1,00
Students Postgraduates Specialists
Scor
eKnowledge about sleep
Knowledge about hypertension
* *
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Stavovi o medicini spavanjaStavovi o medicini spavanja
70,3 71,2 73,4
0,0
20,0
40,0
60,0
80,0
100,0
Students Postgraduates Specialists
Attit
ude
Test
Sco
re
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Sažetak• Sve skupine ispitanika podjednako poznaju problematiku iz područja medicine spavanja.
• Studenti medicine na drugoj godini podjednako slabo poznaju problematiku hipertenzije kao i medicinu spavanja.
• Postdiplomandi i specijalisti pokazali su veće znanje o hipertenziji negoli o medicini spavanja.
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Zaključci• Studenti medicine, postdiplomandi i specijalisti, svi su pokazali razmjerno slabo znanje iz područja medicine spavanja.
• Studenti medicine, kao i liječnici, imaju pozitivan stav o medicini spavanja.
• Naši rezultati ukazuju na potrebu za boljom edukacijom iz medicine spavanja na medicinskim fakultetima i u kliničkim bolnicama.
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Kako naprijed?Kako naprijed?
Probuditi se!
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Kako naprijed?Kako naprijed?
Probuditi se!
Dalmatinski specijalitet: Dalmatinski specijalitet: FJAKAFJAKA
Stanje obamrlosti s potenciranom željom za NIŠTA!
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LABORATORIJ ZA NEUROZNANOST
MEDICINSKOG FAKULTETASVEUČILIŠTA U SPLITU
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PROJEKT OSNIVANJA
LABORATORIJA ZA ISTRAŽIVANJE SPAVANJA
U OKVIRULABORATORIJA ZA KLINIČKU NEUROZNANOST
MEDICINSKOG FAKULTETAU SPLITU I
KLINIČKE BOLNICE SPLIT
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Polisomnografija
•dijagnostička metoda
•u specijaliziranom laboratoriju za istraživanje spavanja
•korisna je u brojnim kliničkim aplikacijama
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PolPoliisomnogrsomnografijaafija EOG - Elektrookulogram EEG - Elektroencefalogram EMG - Elektromiogram EKG - Elektrokardiogram Zvuk iz dušnika (mikrofon) Protok zraka kroz nos i usta Napor pri udisanju grudnog i trbušnog mišićja Pulsna oksimetrija
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LOC
ROC
Left and Right Electrooculogram
Eye Blinks
Electrooculography picks up the inherent voltage of the eye. During eyes-open
wakefulness, sharp deflections in the EOG tracing may indicate the presence of eye blinks.
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LOC
ROC
Left and Right Electrooculogram
During drowsiness and stage one sleep, the eyes begin to slowly roll (SEM’s). Brain wave activity (theta) starts to enter into the EOG tracing as an artifact.
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LOC
ROC
Left and Right Electrooculogram
During REM sleep, the eyes move rapidly under closed eyelids while dreaming. This produces rapid conjugate eye movements which appear as out-of-phase EOG channel deflections.
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C3
O1
Electroencephalography in the Overnight Sleep Study
G1 G2
Paper or computer screen
A2
Differential Amplifier
C3-A2
O1-A2G1 G2
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22.04.23 Zoran Đogaš 59Low EMG during wakefulness and NREM sleep
ROC
Mental/Submental EMG
Total duration of yawn causing increased EMG
Submental EMG records muscle Tone. This is a mandatory
recording parameterfor staging sleep (REM vs. NREM).
Yawns, swallows, and tooth grinding may also increase
muscle tone.
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Open mouth or Clenched Teeth
Differential Amplifier
G1 G2
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Relaxed Jaw
Differential Amplifier
G1 G2
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Electroencephalography (EEG)
Differential Amplifier
G1 G2
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Differential AmplifierG1 G2
Combination of two dissimilar metals
Voltage changes are seen with exhalation and inhalation
Thermocouple
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DifferentialAmplifier
DifferentialAmplifier
DifferentialAmplifier
Tracheal Sound
Piezo Respiratory Effort
Anterior Tibialis EMG
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Poremećaji disanja tijekom Poremećaji disanja tijekom spavanjaspavanja
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Scoring Respiratory EventsScoring Respiratory Events
Obstructive Apnea Central Apnea Mixed Apnea Hypopneas
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22.04.23 Zoran Đogaš 67Obstructive Apnea A complete blockage of the airway despite efforts to breath. Notice the effort gradually increasing ending in airway opening.
Blood oxygen levels reduction to > 3% of baseline value
Inhale
Exhale Airway obstructs Airway opens
Paradoxing
Paradoxing Ends
EKG
Airflow
Thoracic effort
Abd. effort
SAO2
Effort gradually increases
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EKG
Airflow
Thoracic Effort
Abdominal Effort
SAO2
Mixed Apnea
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Central Apnea: These are central apneas (2) with minimal oxygen desaturation. Notice the low SAO2 at the beginning of this tracing. This is associated with a previous apnea.
Both of these events between 13-16 seconds in duration.
Airflow
Thor. Effort
Abd. Effort
SAO2
ECG
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Stadiji spavanjaStadiji spavanja
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Zašto uzimati anamnezu Zašto uzimati anamnezu spavanja?spavanja?
Poremećaji spavanja su česti Poremećaji spavanja su ozbiljan zdr. problem Poremećaje spavanja je moguće liječiti Poremećaji spavanja većinom ostaju
neprepoznati i rijetko se dijagnosticiraju
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Cilj uzimanja anamneze Cilj uzimanja anamneze spavanjaspavanja
Otkrivanje poremećaja spavanja
Procijeniti prisutne tegobe vezane za spavanje
Procijeniti ulogu poremećaja spavanja kao dodatnog čimbenika u drugim bolestima
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Poremećaj spavanjaPoremećaj spavanja
nedostatno spavanje isprekidan san (deprivacija sna) (fragmentiran san)
prekomjerna dnevna pospanost primarni poremećaji
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Poremećaji spavanja: Poremećaji spavanja: Kliničke posljedice Kliničke posljedice
prekomjerna dnevna pospanost
neurobihejvioralni umanjenje sposobnostiporemećaji
povećan mortalitet/morbiditet pad kvalitete života
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Povećana dnevna pospanost: Povećana dnevna pospanost: definicijadefinicija
Pospanost vs. umor Subjektivna procjena potrebe za spavanjem,
osobito u uvjetima niske stimulacije Tablice za procjenu pospanosti
Epworth sleepiness scale (ESS)Stanford sleepiness scale (SSS)
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Poremećaji spavanja: uzrociPoremećaji spavanja: uzroci
Cirkadijani Neurološki Psihijatrijski Navike Srčanožilni Ostali medicinski problemi Lijekovi/kemijske tvari
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Poremećaji spavanja: Poremećaji spavanja: uzroci/klinički poremećajiuzroci/klinički poremećaji
Cirkadijani rad u smjenama/poremećenraspored spavanja
Neurološki RLS/PLMSnarkolepsija
Psihijatrijski poremećaji raspoloženja
Navike loša higijena spavanja, psiho-fiziološka nesanica
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Poremećaji spavanja: uzroci/ Poremećaji spavanja: uzroci/ klinički poremećajiklinički poremećaji
Srčanožilni opstrukcijska sleep apnea
Drugi med. problemi GE refluks, astma, KOPB, bolna stanja
Lijekovi/kemijske alkohol, nikotin, tvari kofein, lijekovi
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Anamneza spavanja Anamneza spavanja ““BEARSBEARS””
Bedtime – vrijeme lijeganja Excesive daytime sleepiness – prekomjerna
dnevna pospanost Awakenings – buđenja tijekom noći
ranojutarnja buđenja Regularity – pravilnost i trajanje spavanja Snoring - hrkanje
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Nesanica - insomnijaNesanica - insomnijaNesanica je osjećaj (ili pritužba) neodgovarajućeg ili nedovoljno kvalitetnog spavanja zbog:•Teškog uspavljivanja•Čestog buđenja tijekom noći i otežanog ponovnog usnivanja •Preranog jutarnjeg buđenja •“Neosvježujućeg” sna
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Nesanica - insomnijaNesanica - insomnija20-40% odraslih
17% drži svoj problem ozbiljnim
4% Amerikanaca uzima lijekove za insomniju
50% bolesnika s kroničnim bolestima
starija dob (> 60 god.), žene, depresija u anamnezi
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Nesanica - insomnijaNesanica - insomnija
Bolesnici s insomnijom:
Češće hospitalizirani
Slabiji uspjeh na poslu
Povećana smrtnost
2,5 x češće automobilske nesreće
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Nesanica - insomnijaNesanica - insomnija
Bolesnici s insomnijom:
U polisomnografiji češći stadiji WK i stadij 1
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Uzroci nesaniceUzroci nesanice•stres •vanjska buka •ekstremna temperatura •promjena u vanjskim uvjetima •poremećaj ciklusa budnosti i spavanja (npr. “jet lag”) •nuspojave lijekova
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Nesanica - insomnijaNesanica - insomnija
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Nesanica - insomnijaNesanica - insomnija